Hand Therapy: Specialized OT in Tune With Patients

Alan Weinstein plays the cello. More specifically, he is a founding member of the Kandinsky Trio, artists in residence at Roanoke College whose innovative chamber music enjoys international acclaim. He is also an assistant professor of cello and bass at Virginia Tech and has given more than 200 master classes at institutions throughout the country. As a professional musician, he is very in tune with his body mechanics and physical condition. He knows that even a small change can affect performance.

So when he began to experience a slight pain in his elbow when he was playing, he paid attention.

“It’s not a natural act to sit for 8 hours a day playing music,” he said. “There isn’t a musician around who hasn’t experienced some kind of physical issue.”

He underwent physical therapy over a period of three years and although it helped while he was doing it, the pain always returned.

“For a few years there, the pain was constant,” he said. “I would have to really monitor myself and sometimes just grit through a performance.”

Weinstein already knew Carilion Clinic occupational therapist Lisa Broyden through group rides with the New River Valley’s cycling community. When he learned she had additional training as a hand therapist and had worked with musicians, he asked her for help.

What Is Occupational Therapy?
The American Occupational Therapy Association describes occupational therapy (OT) as helping people regain their maximum level of independence in their daily activities after an injury or illness results in a change in their level of function. OT is appropriate whether the change in function affects self-care, work or leisure.

“OT comes from the root 'occupation,' which is essentially all the things you need to do throughout your day,” said Broyden.

For musicians, most of those things happen in the upper extremities, from the shoulder to the hand. With a special interest in hand therapy, Broyden has undergone additional training to specialize in arthritis, carpal tunnel and overuse syndromes and other upper extremity issues that limit the use of the hand and fingers.

“If you are a musician, your arms are everything,” she said. “Overuse syndrome—symptoms related to activity that exceeds the biological limits of the tissues involved—is very common among musicians.”

Broyden works with patients who have been referred to her from their primary care provider or a specialist. Once she assesses them, she recommends a plan of care that the provider then approves.

“The providers are the gatekeepers, and they encourage patients to take an active role in their own care, which strengthens the patient-provider relationship,” she said. “A referral for occupational therapy usually means determining what’s going on and developing their treatment plan and then giving the patient a system of management for their symptoms.”

Health care providers are increasingly proactive about recommending OT and hand therapy to their patients.

“They are as interested in avoiding more invasive interventions as the patients are,” Broyden explained.

“I like OT for hand and upper extremity conditions due to the benefits that are achieved by more specific therapeutic programs that aim to improve functional status in day-to-day activities and functions,” he said. “OT is a major component of recovery for trauma and/or injuries that may not initially have surgical indications. There are significant risks associated with all surgeries, and if a patient can have successful recovery and be functional and happy without surgery, OT can play an important role in that non-operative plan.”

Hand Therapy in Action
Broyden’s work with musicians begins with a private concert.

“I have them bring their instrument in and watch them play for a while, so I can see how their body position contributes to their complaint,” she said. “The more information I have, the more I can help them.”

She works with patients from all walks of life, but finds musicians particularly motivated.

“People who have a particular passion—whether music or crochet or knitting—they worry that their symptoms mean the end of their playing,” she said.

As a result, they are engaged in their care and enthusiastic about incorporating the stretches and exercises she teaches them into their daily routines. Alan Weinstein agrees. Together with changes to his diet, an increased focus on core-strengthening exercises and other lifestyle improvements, he credits Broyden for teaching him self-care strategies that finally stopped his pain.

“Like many other musicians, my history with doctors is long,” he said. “But nothing really worked to alleviate this. You compensate for the pain and it makes different muscles behave differently than they should. What Lisa does is give you manageable strategies that you can use to really develop a lifestyle that is pain-free. It’s not a pill or ongoing medication.”

For Weinstein, the key exercises are called nerve glides; they fully extend and contract muscles and tendons in his wrists and forearms, counteracting the repetitive micro-movements that resulted in his overuse syndrome.

He goes back to those exercises whenever the pain reappears.

“Now, I notice numbness or pain beginning, I do the nerve glides and it dissipates immediately,” he said.

Early Intervention
Anna Smith is also a musician. Now 14, she has played violin since an early age and plays at a high level in youth symphony, camps, chamber music and as a duo with her cellist brother, who is 12. A year ago she began experiencing pain during her three-hours-long rehearsals. Her pinky was extending while she played in a way that affected how she held her bow.

“I hesitated to see a doctor,” said Anna’s mother, Carolyn Smith. “What do you say, ‘my daughter’s pinky hurts?' It just seemed like such a small thing.”

But it became a consistent complaint and it was preventing Anna from being able to take on a more challenging repertoire. So Carolyn took her to see Broyden.

As she did with Weinstein, Broyden had Anna bring her violin to their first meeting.

“We identified a lax ligament in her first pinkie joint,” Broyden said. “That caused the end joint to bend excessively and put a strain on the first joint. So I made her a splint to hold the first joint slightly bent, which minimizes the pressure on the last joint.”

“I haven’t heard a single complaint since,” said Carolyn Smith.

Anna quickly mastered the etude that she was learning when the pain began, and she wears the splint every time she plays.

Not Just Musicians
Hand therapy is not just for musicians. Broyden treats people who are coping with Parkinson’s disease, recovering from stroke, suffering from arthritis and regaining strength and function after having a cast removed.

“Many office workers with hunched-over shoulders experience decreased function,” she said. “And we’re seeing more kids with issues that can be helped by OT.”

Broyden offers advice for when someone should seek medical or therapeutic care.

“If you’re realizing that the more you’re doing something, the more it hurts, and you’ve tried conservative approaches such as ibuprofen and rest—or if it recurs—then go see your health care provider.”

Watch the video below to see Alan Weinstein in action and see the benefits and results of his therapy first-hand.